Recurrent Unremitting Patellar Tendonitis/ Tendonosis Rehabilitation Program

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I. Phase I

Goals: Diminish pain and inflammation Promote tendon healing Improve quadriceps strength Enhance flexibility Control functional stresses

Treatment Regimen: • Hot packs applied to knee • Ultrasound to patellar tendon • Transverse friction massage • Warm-up bicycle (10-12 min.) • Stretch (hamstrings quadriceps, gastroc) • Application of pain stimulation to each side of patella tendon or infra-patellar fat pad x 10 minutes • Electrical stimulation parameters • Waveform: Russian • Frequency: 2500 H2 pulse; width: 200 MS; Rate: 50/sec • 60 pulses per second (pps) • duty cycle 10 on/10 off; ramp of 1 second • pad placement- 1”x1” electrodes placed on each side of inflamed/painful tendon (After 3 minutes, palpate tendon, should be less painful and becoming numb, if not, move electrodes) • Quadriceps strengthening program (Level I) • E-stim to quadriceps* • Quad sets* • SLR flexion* • Hip adduction/abduction* • Vertical squats (tilt board) • Hip flexion/extension • Toe-calf raises • Bicycle (15-20 min.) *Monitor subjective pain level response (goal level 5-7) • Pool program • Stretch (aggressive stretching) • Laser • Cryotherapy

II. Phase II

Emphasize eccentric training for quadriceps

Goals: Gradual increase stress to patellar tendon Enhance quadriceps strength Improve flexibility Gradual increase functional activities

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Treatment Regimen: • Hot packs or warm whirlpool • Ultrasound to patellar tendon • Transverse message to patellar tendon • Active warm-up bicycle (10-12 min.) • Stretch (hamstrings, quadriceps, gastroc) • Application of pain stimulation • Strengthening program (Level II) • Leg press (90-0o) and (45-100o)-(emphasize eccentrics) • Hip add/abduction • Hip flex/extension • Wall squats (0-70o) • Lateral step-up (foam)-(emphasize eccentrics) • Front lunges- (emphasize back leg) • Knee extension (progress from eccentric to concentric)-(emphasize eccentrics) • Leg press (progress from concentric to eccentric) • Hamstring curls • Toe-calf raises • Bicycle/stairmaster • Control forces to knee • Enhance hip & ankle strength & stability • Core stability *Monitor subjective pain level response (goal 5-7) • Aggressive stretching • Laser • Cryotherapy

III. Phase III

Goals: Gradually increase applied loads Functional training Enhance lower extremity strength Improve flexibility

Treatment Regimen: • Hot packs to knee • Ultrasound to patellar tendon • Transverse message • Active warm-up • Stretch • Application of noxious electrical stimulation protocol • Strengthening program (Level III) • Continue previous exercises • Continue eccentric progression • Leg press • Hip machine • Wall squats • Tilt board squats • Lateral step-ups • Front step-downs • Agility drills

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• Lunges onto unstable surface • Step-ups on unstable surface • Single leg balance on unstable surface • Plyometric program • Initiate two-legged jumps • Progress to one-legged jumps *Monitor pain level (goal level 5-7) • Progress to running program • Backward running • Lateral movements • Forward running • Laser Therapy • Stretching

IV. Phase IV

Goals: Sports specific training Continue stretching/flexibility program Continue strengthening program

Treatment Regimen: • Heat and ultrasound (if needed) • Active warm-up • Stretching • Continue strengthening program • Initiate sport specific drills and training • Progress to practice situation • Stretch • Ice (if needed)

Pain (noxious) Stimulation Protocol Clinical muscular electro-stimulator

• Specific parameters . Frequency: 2500 Hz pulse width: 200MS . Rate: 60 pulses per second (pps) . Ramp: 1 sec . Waveform: Russian . Duty cycle: 10 on/10 off . Time: 12 minutes

- Electrode placement • 1” X 1” electrodes placed on each side of painful tendon or infrapatella fat pad

* after 3 minutes palpate tendon, if not becoming less painful or numb, move electrodes